20879APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification IV °
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D� 20879
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CITY OF CUPERTINO-BUILDING DIVISION
c
Lk. No:
�• • �' QV
APPLICATION / PERMIT�—
BUTLDINGELECnUCAI PLUMBING -MSCI IANICAL
CATEGORY
CONTROL M
O
Amhlteci/Engineer.. '' 11 •• Lk. No:
C 1'l� INC
QTY ELECTRIC PERMIT
FEE
BUILDING PERMIT INFO
Address: ''r CAP-1POELL AVE,PERNRTISSUANCE
r (�j•
'F=� a{�
LFT
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(oomrwn
ingwith Seoio^7000)of Dlvidon3oft�hse Businnsand PmfessionsC e,aoo my
t 11 fora And f
APPLIANCESRESIDENTIAL
JOB WFS M-I[ON
PAN[LS
LAffect.
mmnseee clam N /
Date Contndor
2014000 AMPS
ARCHITECTS DECLARATION
I understand my plan shall be used d public records.
Licensed Professional
OVER lODO AMPS
SQ. FT.PLO VRA
II 6
�S/'SrQ.Yr.
• -�*, y
SIGNS ELECTRICAL
OWNER -BUILDER DECLARATION
I hereby afRrm that I am exempt from the Contractors License Law for the
SPECIALCIRCUIT/MISC
TEMP. METER OR POLE INST.
following reason. (Section 70115, gusineaa^d Pro&ssions Code: Any city or
muntywhich requires a permit to construct, alter, Improve, demolish, °reepair
anystmc mpdortoibhmance,aWrequimatheappgontforsuchpermitto
file a signed statement that he is licensed pursuant to the provisions of the
POWER DEVICES
SWIMMING POOL ELECTRIC
/ OUTLE3SSWITCHE4HXTURES9
l0.
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi.
sl°n3°fthe Businessand Professba Code)orthathebexemptihenfromand
the basis for the alleged exemption. Any violation of Stolon 70115 by any
applicant for a permit subjects the a pphcant to a civil penalty of not room than
Q� VALUATION O
Cl l
NEW RESIDENTIAL ELLCTR SQ'r'
fiv�undred dollars ($500).
1, as owner of the property, or my employees with wages as their sole
STORICq
TYPE CONSTRUCTION
compensation, will do the work and the strucium Is not Intended or offered for
sale (Sec. 7044, Business and professions, Code: The Contractors License law
does not apply to an owner of property who builds or improves therm^,and
does such work himself or through his own employed, provided that such
OCC.CROUP
RFS. UNITS
Improvements are not Intended proffered for sale. If, however, thebullding or
Improvementb.1dwithlnoayearofmmplei. ,theowner-buRdcrwlllhave
TOTAL:
t115jurden of proving that he did not build or Improve for purpose of sale.).
U L as owner of the property, am exclusively contracting with licensed
mntradon to construct the project (Sec 7044, Business and Professions Code:
QTY. PLUMBING PERMIT
FEE
FLOOD ZONE
APN
PERMIT ISSUANCE
�s
The Cmntndor's License law don not apply to an owner of property whogl•TpR-DRAIN
Wilds or Improves thereon, and who contracts for such p(ojmA with a
Cg RI(ador(s) licensed pursuant to the Contractor's License Law.
LJ I am exempt under See, B k P C for this mown
&VENT -WATER (EA)
eco
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIJIF
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N
RECEIPT a
Owner Date
WOR
OBIO.tAN COMP ENSATION DECLARATION
❑ I here affirm that I have • le rue or consent to pythe re, ora
MO ,Lab of Worken'Compeaation Iauranama artifled copythereof (Sec,
lab C.I
FTXTURIIS. PER TRAP
18 w'1
O cU/
Sp{OOL TAX Y_ N_
REGI'
1
l GAS EA. SYSTEM-]INC.4OUTLETS
�e�
PARK EFF. Y N
Policy
1'oliry a
B
RECEGAS
EA. SYSIPM-OVER 4IRA)
Com any
OING III'
BUILDING DI VISION FOES
�CzdiOed copy is hereby te ci
Certeled mpybfiled withh the cityInspection division.
�ty
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
�•
CERTIFICATE OF EXEM PTION FROM WOR KER S'
GREASE TRAPPAID910--?d
COMPENSATION INSURANCE
(Title section need rad be completed I(the permit intercom hundred dollars
(f100)orlessJ
a
1 artily that In the performance the work for which title permit le issued,
I shall not employ any person in any manner At, As to become subject to the
Worker Compemation Laws of California. Date
Date Regi t#
SEWER -SANITARY -STORM EA. 200FT,
WATER HEATER W/VENT'/ELECTR
ENERGY FEE Y_ N
PAID
WATER SYSTEM/TREATING
Applicant
NOTICE TO APPLICANT: U, after raking this Certificate of Exemption, you
should be.. subject to the Workers' Compeaatlon provisions of the Labor
ate Recei t#
NEWRESIDENTIALPLMR. _SOFT.
TOTAL: A LP
Code, you must forthwith comply with such provbioa orthls permit shall be
deemed revoked.
BUILDING
FEE
SEISMIC FEE • V
CONSTRUCTION LENDING AGENCY
Ihembyaffr thatthereise coa[ruction lending agency for the perform
once of the work for which this permit is lamed (Sec. 3097, Clv. C.)
ELECTRIC FEE a
QTY. MECHANIC L PERMIT
PLUMBING FEE
Lenders Name
Lenders Address
I anlfythatl have read thlaappliettionand statethat theabove Information
b correct.lage- to comply with all city and musty, ordinances and pate laws
MECHANICAL FEE
PERMIT ISSUANCE
FFE�El
FEES PAID:
reletingto building coatmction, and hereby authorize representatives ofthis city to enter upon the abovcmentioned property for inspection purposes.
(We) agree to save, Indemnify an d keep ml
p haress the City of Cupertino
against liabilities,Judgments, mks and expenses which may In any wayaccrue
agala said CitZ i^ conseyue aoLthe gra rating of this mtIt.
//n l /µ o �0 6
Date ReCCI t#
P
ALTERORADDTOMECH.
AIR HANDLING UNIT(TO ID,ODO CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER IO,ODOCFM)
CONSTRUCTION TAX
�atoffi of Applicant/ or radorpate
EXHAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HAZAR DOUS MATER IALS DI SCLOS E
Willtheappllont or towns building occupantstore or handle hazardous
naterlal as dented by the Cupertino Municipal Code, Chapter 9.12, and the
Health and ❑ Y. Safety CedeSSeNon2S532(a)?
Date RCCCI t#
HFATINGUNIT(MI00,00DBTU)
HEATING UNIT (OVER 100,00) HIM
7
TOTAL:
VEN•f2LATION FAN (SINGLE RESOD)
a(�
ISSUANCE DATE
Will the applicant or future building occupant use equipment or devices
which emit hazardous air rontaMants as defined by the Bay Area Air
BOILER -COMP (31 IF OR 100,000 BTI)
—
'Qu a lity Management District?
1„I—I Y. No
BOILER-COMP(OVER100,D00 BTU)
`shave read the h.,pus nutedals requirements under Chapter 6.95 of
the Glifarnia lTesllh k SafetyCode, Sedioa 255D5, 25533 and 25537. I
riiA TCC
NEW RESIDENTIAL MECH. SQ,F7
understand that if the building does not currently have a tenant, that It is my
ACCP
respon lbllity to notify the occupant of the requirements which =at be met
prior m Lvuance of a Certilicatc of Ompanry.
OCT j990
ISSUEDB
Owner or authorized agent- Date
TOTAL:
OFFICE COPY